Valley Manor And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for three of 17 sampled residents (Resident #13, #30 and #67) when the facility did not include activity preferences for Resident #13, did not include fall interventions for Resident #67 and when the facility did not address behaviors for Resident #30. The facility census was 67.Review of the facility's Comprehensive and Person-Centered Care Plan policy, revised March 2022, showed:-A person centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;-The comprehensive, person centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well being;-Services provided for or arranged by the facility and outlined in the comprehensive care plan are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when facility staff did not provide timely showers for three of 17 sampled residents (Resident #45, #56, and #59). The facility census was 67. Review of the facility policy, Shower/Tub bath, revised February 2018, showed:- The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin;- Documentation included: the date and time other shower/tub bath was performed; then name and title of the individual who assisted the resident with the shower/tub bath; all assessment data (e.g. any reddened areas, sores, etc. on the resident's skin) obtained during the shower/tub bath; how the resident tolerated the shower/tub bath; if the resident refused the shower/tub bath, the reasons why and the intervention taken; the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide an ongoing activities program for three of the 17 sampled residents (Resident #67, #8 and #13) when the facility staff failed to provide individualized and meaningful activities in accordance with the facility assessment and resident preferences. The facility census was 67. Review of the facility's Activity Programs policy, dated June 2018, showed:-The activities program is provided to support the wellbeing of residents and to encourage both independent and community interaction;-The activities program is ongoing and includes facility organized group activities, independent individual activities and assisted individual activities;-Individual and group activities are provided; -All activities are documented in the resident's record;-Adequate space and equipment are provided to ensure that the needed services identified in the resident's plan of care are met. Review of the activity Calendar dated October 2025 showed on Monday through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned for three residents (Residents #10, #18, and #56 ) and additionally failed to properly store oxygen accessories at the bedside for one resident (Resident #56) resulting in possible exposure to bacteria during oxygen usage. This affected three of 17 sampled residents. The facility census was 67.No policies were provided by the facility related to oxygen tubing care or storage. 1. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/9/25, showed:- The Resident had moderate cognitive impairment;- The Resident had been dependent on nursing staff for all cares;- Diagnosis of dementia, Chronic Obstructive Pulmonary Disease (COPD - lung and airway diseases that restrict breathing), and heart disease. Review of the Resident's Care Plan, dated 12/16/25, showed:-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to store drugs and biologicals in locked compartments under proper temperature controls when the facility failed to ensure refrigerator temperatures were accurately checked and recorded to ensure medications were being stored at a safe temperature. This had the potential to affect all residents who received refrigerated medication. The facility census was 67.Review of the facilities Medication Labeling and Storage policy, dated February 2023, showed: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light control; -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manor. 1.Observation of Medication room [ROOM NUMBER] on 12/16/25 at 10:11 A.M. showed: -The temperature log for the station 4 medication room fridge was kept in a binder outside of the medication room at the nurses station; -The month of November…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when, dietary staff did not change gloves between clean and dirty tasks and when facility staff did not apply Personal Protective Equipment (PPE) when they provided care and treatment for two residents (Resident #61 and Resident #46) and when the facility failed to have an infection surveillance program. The facility census was 67. Review of the facility's Personal Protective Equipment – Using Gloves policy, dated September 2010, showed:-Gloves are used to prevent the spread of infections;-Gloves are used to protect wounds from contamination;-Gloves are used to protect hands from infectious material;\-Wash hands after removing gloves;-Use gloves when touching excretions, secretions, blood, body fluids. Review of the facility's Handwashing/Hand Hygiene policy dated October 2023, showed:-All…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that one of two sampled residents, Resident #28, identified with a pressure ulcer, received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing when the facility failed to properly follow physician's orders when performing wound care. The facility census was 67.No policies were provided by the facility related to wound care or pressure injuries. 1. Review of Resident #28's Quarterly MDS dated [DATE], showed:-No cognitive impairment;-Assistance of two staff for bed mobility and transfers;-At risk for pressure ulcers;-Pressure ulcer present on admit;-Diagnoses included diabetes, high blood pressure and anemia. Review of the resident's care plan dated 12/08/25, showed:-The resident had a pressure ulcer;-Provide wound care per treatment order. Review of the resident's Physician's Order Sheet (POS) dated December 2025, showed an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure one nurse aide (NA) A completed a nurse aide training program within four months of his/her employment in the facility. The census was 67. The facility did not provide a policy regarding Nurse Aide training. Review of Nurse Aide (NA) A's employee file showed:-Date of hire 4/21/25; -No documentation that NA A had completed a nurse aide training program was found.During an interview on 12/15/24 at 10:11 A.M., NA A said:-He/She had not passed the knowledge part of the Certified Nurse Aide (CNA) test;-He/She worked as an NA only; -He/She was not sure when he/she would take the test again;-He/She was not aware he/she needed to be certified within 4 months of hire.During an interview on 12/18/25 at 1:15 P.M., the Director of Nursing said:-She was not aware that NA A had been working at the facility more than 4 months;-She was unsure why NA A was still working at the facility.During an interview on 12/18/25 at 1:25 P.M., the Administrator said:-She was not aware that NA A had been working at the facility more than 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to honor one resident's religious preferences when the facility failed to offer a suitable substitute at the lunch meal service for Resident #19, who was assessed and documented as not being able to eat pork products. This affected one out of 12 sampled residents. The facility census was 67. Review of facility policy, Food and Nutrition Services, revised October 2017, showed:- The multidisciplinary staff will assess each resident's nutritional needs, food likes, dislikes and eating habits that affect eating and nutritional intake and utilization;- Reasonable efforts will be made to accommodate resident choices and food preferences;- Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident;- If an incorrect meal is provided to a resident nursing staff will report it to the food service manager so that a new food tray can be issued;1. Review of Resident #19's Quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The census was 67. Review of the facility Antibiotic Stewardship policy, dated December 2016 showed:- The purpose of antibiotic stewardship is to monitor the use of antibiotics in our residents and to include training, orientation, and education of staff with emphasize on the importance of antibiotics stewardship, and inappropriate use of antibiotics; - Antibiotics usage and outcome will be collected and documented using a facility-approved antibiotics surveillance tracking form; - The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship.The facility did not provide complete Antibiotic Stewardship…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control to be responsible for the facility's Infection Prevention and Control Program. The census was 67.Review of the facility Components of Infection Control policy, undated, showed:- The Infection Preventionist is a person designated to serve as a coordinator of the infection prevention and control program;- Generally, it is best to have a registered nurse in this position;- Infection Preventionist must complete the required Centers for Disease Control (CDC) course on Infection Preventionist training.Review of the facility's current Infection Preventionist's training showed:- Only modules one through 15 of the 23 module, CDC required course had been completed;- No course completion certificate was provided.During an interview on 12/17/25 at 11:44 A.M., the Assistant Director of Nursing (ADON) and Infection Preventionist (IP) said:- She was not sure how to get further documentation of her IP course…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to administer medications for pain management in accordance with the resident's physician orders, which caused unnecessary pain for one Resident (Resident #1) of five sampled residents. The facility census was 63. Review of the facility policy titled, Pain Assessment and Management, revised April 2025, showed: -Establish a treatment regimen specific to the resident based on consideration of the following: a) The resident's medical condition; b) Current medication regimen; c) Nature, severity, and cause of the pain. -The medication regimen is implemented as ordered; -Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications; -Contact the provider immediately if the resident's pain is not adequately controlled. Review of the facility's undated Medication Administration and Scheduled Medication Administration policy showed: -Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency and may be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, did not ensure refrigerator and freezer temperatures were checked daily, did not ensure proper function of dishwasher by testing and logging it daily, did not use sanitizer solution on kitchen food preparation surfaces, did not keep food stored off the floor, did not ensure proper storage and labeling of foods, and when dietary staff did not wear hairnets prior to entering kitchen. The facility census was 68. 1. Review of facility policy, food receiving and storage, revised November 2022, showed: -Dry Food Storage: -Food in designated dry storage areas are kept at least 6 inches off the floor. -Refrigerated/Frozen storage: -All foods stored in the refrigerator or freezer are covered, labeled, and dated with use by date. -Refrigerated foods are stored in such a way that promote adequate air circulation around food storage containers; -Foods in walk in are stored…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to respect resident rights of four residents out of the 17 sampled residents, when the facility failed to provide grooming for one resident (Resident #10), failed to respond to call lights within a timely manner for one resident (Resident #22), and additionally failed to preserve the dignity of two residents, when the staff did not provide mouth care to a dependent resident, and did not keep bedside urinal away from one resident's drinks (Resident #34, and Resident #63) The facility census was 68. Review of the facility's Resident Rights Policy, undated., showed: - Residents have the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. - Receive services and care outlined in the resident's care plan. - Every resident has the right to be treated with dignity and respect. Review of the facility's undated Call light policy., showed: To ensure timely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to consider the concerns and recommendations of the resident council members and failed to communicate with the council regarding their concerns as reported by seven of the eight residents who participated in a group meeting. This had the potential to affect all the residents. The facility census was 68. Review of the facility's policy for recording and investigating grievances/complaints, revised April, 2017 showed, in part: - All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances; - Upon receiving a grievance and complaint report, the grievance and complaint report, the grievance officer will begin an investigation into the allegations; - The investigation and report will include: the date and time of the alleged incident; the circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts of the alleged incident; the resident's account of the alleged…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to hold residents' moneies separate from facility money when they did not reiumburse residents and/or their responsible partiies after the residents were discharged , which affected nine of 17 sampled residents. The facility census was 68. Facility did not provide a policy on refunds; Review of Resident Rights Policy, undated, showed: -Resident has a right to manage their financial affairs, including right to know , in advance, what charges a facility may impose against their personal funds; -If a resident chooses to deposit personal funds with facility, upon written autohrization of a resident, facility must act as a fiduciary of resident's funds and hold, safeguard, manage, and account for all personal funds. -Facility must no timpose a charge aganist personal funds of a resident for any item or service for which payment is made under Medicaid or Medicare; -During course of a covered Medicare or Medicaid stay, facilityies must not charge a resident for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to clarify the code status (whether the resident wished to have cardio-pulmonary resuscitation- CPR) of six of the 17 sampled residents, (Resident #22,#63,#6,#18,#29, and #33), and failed to ensure the appropriate code status was listed in the medical record and care planned correctly. The facility census was 68. Review of the facility's Advance Directive Policy dated April, 2013., showed: -Advance Directives will be respected in accordance with state law and facility policy. -The physician will provide an order for Do Not Resuscitate or Full Code. -The care plan will reflect the residents treatment preferences of their Advance Directive. -The Intradisciplinary team will review the Advance Directives ongoing reviews of each residents Advance Directive as needed and yearly. -The Director of Nursing or designee will ensure that appropriate physician orders for Advance directives are obtained and documented in the resident's medical record, and plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for Resident #23, and common areas on the 200 & 300 halls. The facility census was 68. Review of the facility's undated Resident Rights Policy., included the resident has the right to live in a safe, clean, and homelike enviornment. 1. Review of Resident #23's 5 Day Medicare MDS (Minimum Data Set), a mandatory assessment completed by facility staff, completed on 5/17/24., showed: -The resident was re-admitted from hospital with infected hardware from hip repair; -History of Multi Drug Resistant Organisms; -Impaired Cognition; -Assistance with all Activities of daily living (ADL); -Diagnoses: Anxiety, Delusional Disorders (altered reality), Fracture of left femur bone, Significantly impaired mobility upper and lower extremities, as well as back and spinal disorders, and Depression. Observation on 7/7/24 at 10:05 AM showed: -Resident lying on bed with no blanket, sheet only, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to ensure residents knew how to file a grievance. This affected any resident wanting to file a grievance. The facility census was 68. Review of the undated resident rights, showed, in part: - Federal regulations guarantee residents certain rights and the facility must meet these requirements; - Regular in-services should include education about resident rights; - Resident has the right to voice grievances to facility or other agency that hears grievances without discrimination of reprisal and without fear of discrimination or reprisal; - Resident has the right to and the facility must make prompt efforts by the facility to resolve grievances resident may have, in accordance with this paragraph; - Facility must make information on how to file a grievance or complaint available to the resident; - Facility must establish a grievance policy to ensure prompt resolution of all grievances regarding residents' rights contained in this paragraph; - Upon request, provider must give a copy of grievance policy to resident Grievance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop individualized person centered comprehensive care plans for three of 17 sampled (Resident #18, #43, and #34) when shower preferences (Resident #18), shaving and nail care preferences (Resident #43), comfort care measures (Resident #34), oral care (Resident #34), risk for skin integrity (Resident #34), repositioning of resident (Resident #34) , and therapeutic activities and psychosocial needs (Resident #34) were not care planned. The facility census was 68. Review of facility policy, Care Plans Comprehensive Person-Centered, revised March 2022, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. -Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to ensure staff followed professional standards when staff failed to administer eye drops correctly which affected one of the 17 sampled residents, (Resident #26), failed to administer the correct dose of Tylenol (used to treat minor pain) for Resident #, failed to administer Flonase nasal spray (used to treat seasonal allergies) for Resident #21, and failed to allow the fingertip to air dry before obtaining the blood sugar for Resident #4 and #41. Additionally the staff failed to obtain a physician's order to obtain blood sugars for Resident #4. The facility census was 68. The facility did not provide a policy for administration of nasal sprays. Review of the manufacturer's guidelines for Flonase nasal spray, revised March 2016, showed, in part: - Blow your nose to clear your nostrils; - Close one nostril. Tilt your head forward slightly and keeping the bottle upright, carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose and while breathing in, press firmly and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based ob observations, interviews, and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of the 17 sampled residents, (Resident #18, #22 and #25), failed to provide AM care for Resident #25, and failed to ensure showers were completed for for Resident #10, #18, #29 and #43. Additionally, the facility failed to ensure shaving was completed for Resident #29 and #43. The facility census was 68. Review of the facility's policy for shower/tub bath, revised February, 2018, showed, in part: - The purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin; - Documentation included: the date and time other shower/tub bath was performed; then name and title of the individual who assisted the resident with the shower/tub bath; all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when staff failed to lock residents' wheelchairs during transfers (Resident #31), failed to close base of legs during transfer (Resident #31), transfering resident in a hoyer with only one staff present (Resident #6) and staff locked brakes of lift (Resident #25) which affected three of 17 sampled residents, (Resident #31, #6 and #25). The facility census was 68. Review of facility policy, Lifting Machine, Using a Mechanical, dated July 2017, showed: -At least 2 nursing assistants are needed to safely move a resident with a mechanical lift. -Make sure lift is stable and locked. -Make sure all necessary equipment (slings, hooks, chiains, straps, and supports) are on hand and in good condition. -Place the sling under the resident. Visually check the size to ensure it is not too large or too small. -Lower sling bar closer to the resident. -Attach sling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure staff maintained the hydration status for five of the 17 sampled residents, (Resident #1, #10, #25, #58 and #63), when staff did not pass fresh ice water to the residents or offer thickened fluids to residents on special diets during the day or overnight hours. The facility census was 68. Review of the facility's policy for Resident Hydration and Prevention of Dehydration, dated October 2017 showed, in part: - The purpose is to ensure each resident maintains, to the extent possible, acceptable parameters of nutritional and hydration status and the facility provides nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment; - Based on a resident's comprehensive assessment, the facility must ensure that each resident is offered sufficient fluid intake to maintain proper hydration and health; - Nurses' Aides will provide and encourage intake of bedside snacks, meals, fluids,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to discard expired medications and biologicals stored within the medication room. The facility census was 68. The facility's undated policy for storage of medications showed it did not address expired medications. Observation and interview on 7/9/24 at 10:06 A.M., of the central supply cabinet showed: - Unopened bottle of Calcium 600 milligrams (mg.) with Vitamin D (supplement), expired 6/24; - Unopened bottle of Zinc Sulfate 220 mg., for dietary supplement, expired 3/24; - A box of Bisacodyl Suppositories used for constipation, expired 11/22; - The Assistant Director of Nursing (ADON) said he/she thought Certified Medication Technician (CMT) C checked for expired medications. The expired medications should be destroyed and not used. During an interview on 7/10/24 at 12:50 P.M., the Administrator said: - Medical Records or CMT C should check for expired medications every Tuesday. There should not be expired medications in the room. We have trained staff when pulling medications to look at the expiration dates.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed to ensure meals were served to meet the needs of the residents when staff failed to prepare food according to the registered dietician approved recipes, failed to follow dietary preferences, and failed to post a list of available menu substitutions for residents. This deficient practice affected five of seventeen sampled residents, (Resident #22, #21, #48, #31 and #32) The facility census was 68. The facility did not provide a policy on menus and nutritional adequacy. 1. Review of Resident #22's Quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 5/28/24 showed: - Cognitive skills intact; - Upper extremity impaired on one side; - Lower extremity impaired on both sides; - He/She required set up assistance for meals; - Diagnoses included: Paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), Peripheral vascular disease (a circulatory condition in which narrowed blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature and burnt food was served to 10 of 17 sampled residents (Resident #21, #48, #35, #10, #27, #32, #41, #43, #3, and #32) The facility had a census of 68. Review of facility policy, food safety requirements, dated 9/1/21, showed: -Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. -When preparing food, staff shall take precautions in critical control points in food preparation process to prevent, reduce, or eliminate potential hazards. -Holding - staff shall monitor food temperatures while holding for delivery to ensure properly hot and cold holding temperatures are maintained. Staff shall refer to the current FDA food Code and facility policy for food temperatures as needed. -Ready-to eat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure infection prevention measures where followed when the facility staff failed to place three residents on enhanced barrier precautions ( Residents #63, #34, and #23) and failed to maintain proper infection prevention practices when providing care for resident with a urinary catheter (Resident #58) out of the 17 sampled residents. The facility census was 68. Review of the facility's Infection Control Compliance Policy, dated August 2019., showed: - Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and procedures. - The infection preventionist or designee will monitor the compliance and effectivness of the infection prevention and control practices. - Program oversight including planning, organizing, implementing, operating, monitoring, and maintenance of all elements of the program and to ensure that the facility's intradisciplinary teamis involved…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 68. The revised facility Antibiotic Stewardship policy,dated December 2016 showed in part: The purpose of antibiotic stewardship is to monitor the use of antibiotics in our residents and to include training, orientation, and education of staff with emphasize on the importance of antibiotics stewardship, and inappropriate use of antibiotics. Antibiotics usage and outcome will be collected and documented using a facility-approved antibiotics surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship. 1. The facility did not provide Antibiotic Stewardship…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interviews, and record review, the facility failed to serve meals according to scheduled meal times. This affected one of 17 sampled residents . This had to potential to impact all residents in the community. The facility census was 68. Review of facility policy, food safety requirements, dated 9/1/21, showed: -Foods will be stored, prepared, distributed, and served in accordance with professional standards of food service safety; -Food and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of danger zone; -Timely distribution of all meals/snacks. Observation of posted meal times showed: -Dining served in dining room [ROOM NUMBER]:00 A.M., hall trays 9:00 A.M.; -Lunch served in dining room [ROOM NUMBER]:00 P.M., hall trays 1:00 P.M.; -Dinner served in dining room [ROOM NUMBER]:00 P.M., hall trays served 6:00 P.M. 1. Review of Resident #22's Quarterly Minimum Data Set (MDS, a federally mandated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents received services with reasonable accommadtion of the residents' rights and preferences when staff did not honor four of 15 sampled residents, (Resident #6, #8, #11, and #15) preferences for having at least two showers a week and failed to ensure staff provided bedtime snacks for four sampled residents (Residents #8, #11, #15, and #48). The facility census was 60. Review of the facility's policy for bathing and showering, revised February 2018, showed, in part, the purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation included: - The date and time the shower/tub bath was performed, the name and title of the individual who assisted the resident with the shower; all assessment data (any reddened areas, sores, etc. on the resident's skin) obtained during the shower; - If the resident refuses the shower, the reason why and the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made four medication errors out of 28 opportunities for error, a medication error rate of 14.29%, which affected two of 15 sampled residents, (Resident #41 and #52). The facility census was 60. Review of the facility's policy for administering medications, revised April 2019, showed, in part: - Medications are administered in a safe and timely manner, and as prescribed; - Medications are administered in accordance with prescriber orders, including any required time frame. Review of the facility's policy for instillation of eye drops, revised January 2014, showed, in part: - The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes; - To steady the eye dropper during the instillation process, rest your hand on the bridge of the resident's nose or on his/her forehead; - When administering two or more different eye drops allow three to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to ensure they prepared food under sanitary conditions when they failed to keep food labeled, dated, and sealed. The facility census was 60. Review of Labeling and Dating Foods (Date Marking) dated 2016 showed: -Date marking for dry storage food items o Once a case is opened, the individual food items from the case are dated. -Date marking for refrigerated storage food items o Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in -first out method of rotation; o Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturers expiration date; - Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure staff treated residents in a manner that maintained their dignity when staff stood to assist residents to eat which affected three of 15 sampled residents, (Resident #26, #27 and #261). The facility census was 60. Review of the facility's policy for dignity, revised February 2021, showed, in part: - Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; - Residents are treated with dignity and respect at all times; - The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay; - When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. 1. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify the resident or responsible party when a resident's money reaches $200 within the Supplemental Security Income (SSI) (program provides monthly payments to adults and children with a disability or blindness who have income and resources below specific financial limits. SSI payments are also made to people age [AGE] and older without disabilities who meet the financial qualifications.) resource limit ($5,301.85) in the resident trust account. This affected one resident who the facility held funds for (Resident #6). The census was 60. Review of the Resident Trust Fund Management policy dated December 2021 showed: - The facility resident funds are to be maintained in a bank checking account used exclusively for those funds. Transactions are to be handled and records are to be kept in accordance with established directives and in conformance with State and Federal requirements. Timely reporting to the Accounting Office regarding resident trust fund…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.